Confined Space Entry Permit

Confined Space Entry Permit

---

Section 1: Space Identification

• [ ] Manure pit/storage
• [ ] Well/cistern
• [ ] Fuel tank
• [ ] Water tank
• [ ] Septic tank
• [ ] Other: _________________

Section 2: Personnel

Entry Team

Section 3: Hazard Assessment

Atmospheric Hazards

Physical Hazards

Section 4: Atmospheric Testing

|------------|----------------|------------------|-----------------| | 4-Gas Monitor | | | | | Other: | | | |

Pre-Entry Test Results

Continuous Monitoring Required?

• [ ] Yes - continuous monitoring during entry
• [ ] No - periodic testing at _____ minute intervals

Periodic Test Results (if applicable)

Section 5: Ventilation

Ventilation Requirements

• [ ] Natural ventilation sufficient
• [ ] Mechanical ventilation required
• [ ] Continuous ventilation during entry

Section 6: Energy Isolation (Lockout/Tagout)

Equipment to be Isolated

Lockout Verification

• [ ] All energy sources identified
• [ ] All equipment locked out
• [ ] Lockout verified by: _________________ Time: _________________
• [ ] Zero-energy state confirmed

Section 7: Personal Protective Equipment

Required PPE (check all that apply)

Section 8: Rescue Equipment and Procedures

Rescue Equipment On-Site

Rescue Plan

• [ ] Entry rescue by trained personnel
• Response time: _________________ minutes
• Contact: _________________ Phone: _________________
• Nearest hospital: _________________
• Distance/time: _________________

Section 9: Communication

Communication Methods

• [ ] Voice - line of sight
• [ ] Voice - hearing distance
• [ ] Two-way radio
• [ ] Hard-wired communication
• [ ] Hand signals (defined below)
• [ ] Rope signals (defined below)

Signal Definitions

Communication Check

• [ ] Communication tested and working
• [ ] Backup communication available

Section 10: Hot Work

• [ ] Yes - complete below

Hot Work Requirements

• [ ] Separate hot work permit completed
• [ ] Fire watch designated: _________________
• [ ] Fire extinguisher within 10 feet
• [ ] Combustibles removed or protected
• [ ] Ventilation adequate for fumes
• [ ] LEL monitoring continuous during hot work
• [ ] 30-minute fire watch after work complete

Section 11: Pre-Entry Verification Checklist

• [ ] Atmospheric testing completed - results acceptable
• [ ] Ventilation established (if required)
• [ ] All energy sources locked out
• [ ] Required PPE available and inspected
• [ ] Rescue equipment in place
• [ ] Communication system tested
• [ ] Attendant briefed and in position
• [ ] Entrants briefed on hazards and procedures
• [ ] Emergency procedures reviewed
• [ ] This permit posted at entry point

Section 12: Authorization

Entry Authorized

---

Section 13: Entry Log

Section 14: Permit Closure

Reason for Closure

• [ ] Work completed
• [ ] Shift change
• [ ] Conditions changed (new hazards, weather, etc.)
• [ ] Emergency evacuation
• [ ] Permit time expired
• [ ] Other: _________________

Closure Verification

• [ ] All entrants have exited the space
• [ ] All equipment removed
• [ ] Space secured against unauthorized entry
• [ ] Lockout/tagout removed (if applicable)

Section 15: Incident Documentation

• [ ] Yes - describe below

_____________________________________________________________________________

---

Amendment Section

Important Reminders

Entry Supervisor Responsibilities

• Verify all conditions of this permit are met
• Authorize entry only when safe
• Terminate entry if conditions change
• Cancel permit when work is complete

Attendant Responsibilities

• Remain at entry point at all times
• Maintain communication with entrants
• Monitor conditions for changes
• Order evacuation if conditions deteriorate
• Summon rescue services if needed
• NEVER enter the space for rescue

Entrant Responsibilities

• Understand all hazards
• Use required PPE properly
• Maintain communication with attendant
• Exit immediately when ordered
• Exit if you detect warning signs

Warning Signs - Exit Immediately

• Unusual odors
• Dizziness or disorientation
• Difficulty breathing
• Irritation (eyes, nose, throat)
• Headache or nausea
• Alarm from gas monitor
• Order from attendant

Emergency Phone Numbers

Permit Filing Instructions

• Complete all sections before entry
• Post this permit at the entry point during entry
• Close permit properly when entry is complete
• File completed permit for minimum of one year
• Review permits periodically for patterns/improvements

This permit helps ensure safety but does not guarantee it. Proper training, equipment, and judgment are essential for safe confined space entry.